Collagen matrix staple line reinforcement in gastric bypass

BackgroundStaple line leaks and bleeding, anastomotic strictures, and marginal ulcers are significant complications of Roux-en-Y gastric bypass (RYGB) for morbid obesity. Reinforcing the staple lines with bovine collagen matrix reinforcement (CMR) might safely decrease the incidence of leaks and bleeding without causing other complications. Our objective was to determine the effect in RYGB of reinforcing the linear and circular gastric staple lines with CMR on the outcomes including abdominal septic events, blood transfusions, and the incidence of stricture and marginal ulceration of the gastrojejunostomy in a private bariatric surgery practice at 2 Surgical Review Committee Center of Excellence community hospitals.MethodsWe performed a retrospective review of prospectively collected data comparing consecutive outcomes of 505 patients undergoing RYGB without CMR from 2005 to 2006 to 568 patients with CMR of the linear and circular gastric staple lines from 2007 to 2009.ResultsThe application of CMR was associated with a significant reduction from 4% to 1% in the incidence of abdominal septic events, including frank staple line leakage, purulent drainage, and abscess. The number of patients needing transfusion showed a trend downward. The frequency of stricture (1%) and marginal ulceration (2%) was unchanged. No gastrogastric fistulas were identified in either group. No evidence of migration of collagen matrix material appeared after CMR. The 90-day mortality rate for each group was .2% and was unrelated to staple line complications.ConclusionThe use of CMR was associated with a significant reduction in the incidence of abdominal septic complications and a trend toward fewer patients needing transfusion. The frequency of stricture and marginal ulceration was unchanged by the use of CMR.     

Longer duration of homelessness is associated with a lower likelihood of non-detectable plasma HIV-1 RNA viral load among people who use illicit drugs in a Canadian setting

Homelessness is common among people who use drugs (PWUD) and, for those living with HIV/AIDS, an important contributor to sub-optimal HIV treatment outcomes. This study aims to investigate the relationship between the duration of homelessness and the likelihood of plasma HIV-1 RNA viral load (VL) non-detectability among a cohort of HIV-positive PWUD. We used data from the ACCESS study, a long-running prospective cohort study of HIV-positive PWUD linked to comprehensive HIV clinical records including systematic plasma HIV-1 RNA VL monitoring. We estimated the longitudinal relationship between the duration of homelessness and the likelihood of exhibiting a non-detectable VL (i.e., <500?copies/mL plasma) using generalized linear mixed-effects modelling. Between May 1996 and June 2014, 922 highly active antiretroviral therapy-exposed participants were recruited and contributed 8188 observations. Of these, 4800 (59%) were characterized by non-detectable VL. Participants reported they were homeless in 910 (11%) interviews (median: six months, interquartile range: 6–12 months). A longer duration of homelessness was associated with lower odds of VL non-detectability (adjusted odds ratio?=?0.71 per six-month period of homelessness, 95% confidence interval: 0.60–0.83) after adjustment for age, ancestry, drug use patterns, engagement in addiction treatment, and other potential confounders. Longer durations of episodes of homelessness in this cohort of HIV-positive illicit drug users were associated with a lower likelihood of plasma VL non-detectability. Our findings suggest that interventions that seek to promptly house homeless individuals, such as Housing First approaches, might assist in maximizing the clinical and public health benefits of antiretroviral therapy among people living with HIV/AIDS.     

Medicaid care management: Description of high-cost addictions treatment clients

High utilizers of alcohol and other drug treatment (AODTx) services are a priority for healthcare cost control. We examine characteristics of Medicaid-funded AODTx clients, comparing three groups: individuals < 90th percentile of AODTx expenditures (n = 41,054); high-cost clients in the top decile of AODTx expenditures (HC; n = 5,718); and 1760 enrollees in a chronic care management (CM) program for HC clients implemented in 22 counties in New York State. Medicaid and state AODTx registry databases were combined to draw demographic, clinical, social needs and treatment history data. HC clients accounted for 49% of AODTx costs funded by Medicaid. As expected, HC clients had significant social welfare needs, comorbid medical and psychiatric conditions, and use of inpatient services. The CM program was successful in enrolling some high-needs, high-cost clients but faced barriers to reaching the most costly and disengaged individuals.     

Causal effect of disconnection lesions on interhemispheric functional connectivity in rhesus monkeys

In the absence of external stimuli or task demands, correlations in spontaneous brain activity (functional connectivity) reflect patterns of anatomical connectivity. Hence, resting-state functional connectivity has been used as a proxy measure for structural connectivity and as a biomarker for brain changes in disease. To relate changes in functional connectivity to physiological changes in the brain, it is important to understand how correlations in functional connectivity depend on the physical integrity of brain tissue. The causal nature of this relationship has been called into question by patient data suggesting that decreased structural connectivity does not necessarily lead to decreased functional connectivity. Here we provide evidence for a causal but complex relationship between structural connectivity and functional connectivity: we tested interhemispheric functional connectivity before and after corpus callosum section in rhesus monkeys. We found that forebrain commissurotomy severely reduced interhemispheric functional connectivity, but surprisingly, this effect was greatly mitigated if the anterior commissure was left intact. Furthermore, intact structural connections increased their functional connectivity in line with the hypothesis that the inputs to each node are normalized. We conclude that functional connectivity is likely driven by corticocortical white matter connections but with complex network interactions such that a near-normal pattern of functional connectivity can be maintained by just a few indirect structural connections. These surprising results highlight the importance of network-level interactions in functional connectivity and may cast light on various paradoxical findings concerning changes in functional connectivity in disease states.     

A multivariate neuromonitoring approach to neuroplasticity-based computerized cognitive training in recent onset psychosis

Two decades of studies suggest that computerized cognitive training (CCT) has an effect on cognitive improvement and the restoration of brain activity. Nevertheless, individual response to CCT remains heterogenous, and the predictive potential of neuroimaging in gauging response to CCT remains unknown. We employed multivariate pattern analysis (MVPA) on whole-brain resting-state functional connectivity (rsFC) to (neuro)monitor clinical outcome defined as psychosis-likeness change after 10-hours of CCT in recent onset psychosis (ROP) patients. Additionally, we investigated if sensory processing (SP) change during CCT is associated with individual psychosis-likeness change and cognitive gains after CCT. 26 ROP patients were divided into maintainers and improvers based on their SP change during CCT. A support vector machine (SVM) classifier separating 56 healthy controls (HC) from 35 ROP patients using rsFC (balanced accuracy of 65.5%, P < 0.01) was built in an independent sample to create a naturalistic model representing the HC-ROP hyperplane. This model was out-of-sample cross-validated in the ROP patients from the CCT trial to assess associations between rsFC pattern change, cognitive gains and SP during CCT. Patients with intact SP threshold at baseline showed improved attention despite psychosis status on the SVM hyperplane at follow-up (p < 0.05). Contrarily, the attentional gains occurred in the ROP patients who showed impaired SP at baseline only if rsfMRI diagnosis status shifted to the healthy-like side of the SVM continuum. Our results reveal the utility of MVPA for elucidating treatment response neuromarkers based on rsFC-SP change and pave the road to more personalized interventions.Subject terms: Predictive markers, Psychosis     

Automatic Intracranial Space Segmentation for Computed Tomography Brain Images

Craniofacial disorders are routinely diagnosed using computed tomography imaging. Corrective surgery is often performed early in life to restore the skull to a more normal shape. In order to quantitatively assess the shape change due to surgery, we present an automated method for intracranial space segmentation. The method utilizes a two-stage approach which firstly initializes the segmentation with a cascade of mathematical morphology operations. This segmentation is then refined with a level-set-based approach that ensures that low-contrast boundaries, where bone is absent, are completed smoothly. We demonstrate this method on a dataset of 43 images and show that the method produces consistent and accurate results.     

Dengue Fever With Hemorrhagic Features in a Special Forces Soldier

Military operations are conducted in a variety of settings. Some settings provide significant U.S. resources for preventive, primary, urgent, andemergency or trauma care. Other operations consist of small numbers of personnel relying on limited internal, improvised, and/or host nation resources. Special Forces often conduct their missions in rural, austere, andremote settings with a small “medical footprint.” Often the supported government has difficulty providing essential services, including medical care. To address this, U.S. Special Forces select andtrain highly motivated individuals to perform medical duties in an exceptionally austere environment devoid of resources. This case highlights those services andthe medical decision-making process required to provide medical care to approach the standard of care in the United States. In this case, the affected individual had dengue fever.